Fields marked * require an entry.

2020 STEM Virtual Camp Application

For questions or more information, contact Liz Robinson at Liz.M.Robinson@heart.org.

Student First Name:*

Student Middle Name:

Student Last Name:*

School Attending?*

Grade in School?*

Why would participating in a STEM program interest you?*

What are you looking to get out of this program?*

Have you ever felt discouraged from pursuing STEM? If so, why?*

How did you learn about this opportunity?*

Please fill in Parent information in the contact information section below:

Yes

Contact Information

Company:

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Email:*